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<br /> <br />Sl.\~m,it 4110.00 Cl{1pl;CltIibr1 {eLAluJ~Jeji <br /> <br />APPLICATION FOR A LOCAL PE'RMl'r OR CHARITY LOCAL PERMIT~h. ~Ll!'!fA ~ <br />OFFICE OF ATTORNEY GENERAL k lAIN cornpde-I AfpJI~ 11)'1 <br />SFN 9338 (07-2003) -:::n' :3gl?J <br />Application for: J(Local Permit * 0 Charity Local Permit (one event per year) <br /> <br />Name of Non-profit Organization r I)),u .' <br />If c t:' (';{.fJ~ t.-u; J J If 4! r ~ /? <br /> <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />J)",V<-. flGlr<1.4L~4;'"1fi!''''' tre-c_ <br />Business Address v City <br /> <br />Mailing Address (if different) / ' <br />/'1t S- 7 1.f;J." ~;1 5,{' <br /> <br />Na~ of Site Where Game(s) ~i11 be Cq~du~ed <br />L 1"1.. -1> ell( "l 9 e " , & r (i f, ..... e ... <br /> <br />, b..J 1. t ...i1.. 1 j <br />fe~le,- <br /> <br />C'ty <br />I l't4 bJt!-1 <br /> <br />Date(s) of Activity <br /> <br />D>""<21.V ;'" S. <br />Title y , <br /> <br />N()i/)I, <br />rYo i/ ,AI -.A 00 S-to :liD) <br />Business Phone Number <br />701 ;;138 -It, 1108 <br />State Zip Code <br /> <br />City <br />'-Ji.. ..;! eo:I!&"'rt' <br />Site Address <br /> <br />State <br />r\, p~ <br /> <br />Zip Code <br />~"'Z 0 7' <br /> <br />State... L jZiP Code CounJr <br />\"., I \k.l. r g .17 P C .......>'5 <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle 0 Sports Pool D Poker * 0 Twenty-one * 0 Paddlewheels' <br /> <br />Check the Game(s) to be Cqpducted: <br />o Bingo ~e <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br /> <br />C c... S <br /> <br />$ <br /> <br />~o, <br /> <br /> <br />4So, <br />?S. <br /> <br />i' <br /> <br />5" (.). <br /> <br />. i <br /> <br />~ vj <br /> <br />, , <br /> <br />, , <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Umit $12,000 per year) <br /> Total: $ /, '}5" <br /> <br />Intended uses of gaming proceeds: <br /> <br />jl v r'" <br /> <br />Hv...Il-h.r <br /> <br />~ 74 ~"'5C"'1 I I?~ ~'C,-j -e <br /> <br />oS eL /Iv <br />/ <br /> <br />Does the organization presently have a state gaming license? [g,qQ" Dyes - If "Yes,. the organization is not eligible for a local permit or charity local <br />permit and should call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has the organization received a charity local permit from this or another clty or county for the fiscal year July 1 through June 30? Q1Ifc) 0 yes _ If .Yes,. <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? ~' Dyes _ If "Yes,. <br />indicate the total value of all prizes previously awarded: $ , This amount is part of the total prize limit of $12,000 per year. <br /> <br />~ <br /> <br /> <br />n's Top Executive Official <br />Vi ,-. ''t'',,~ <br /> <br />Date <br />9 -;( b --1)..5- <br /> <br />?!-@> <br /> <br />Title <br />V,e-. <br /> <br />Business Phone Number <br />76 -.:2.$8'- '3:2./r <br />